MEDICARE: DR. CAROL S POLACEK PHD, FNP, NPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F331894	NY
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	P400947	NY

General Provider Information

NPI Number	:	1164482634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL S POLACEK PHD, FNP, NPP

Provider Business Mailing Address
First Line	:	750 E ADAMS ST
Second Line	:	TU3 SUITE 222
City	:	SYRACUSE
State	:	NY
Zip	:	13210-2342
Country	:	US
Telephone Number	:	315-464-3293
Fax Number	:	315-464-3202

Provider Business Practice Location Address
First Line	:	750 E ADAMS ST
Second Line	:	TU3 SUITE 222
City	:	SYRACUSE
State	:	NY
Zip	:	13210-2342
Country	:	US
Telephone Number	:	315-464-3293
Fax Number	:	315-464-3202

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	10/20/2008

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